title: Laparoscopic right hepatectomy extended to middle hepatic vein after right portal vein embolization.
abstract: BACKGROUND
  Laparoscopic right hepatectomy (LRH) is a complex but feasible procedure. Preoperative portal vein embolization (PVE) can add difficulties that warrant particular technical modifications. A LRH extended to middle hepatic vein after PVE is presented, with special attention paid to specific operative findings and to useful technical modifications.
  
  
  METHODS
  A 62-year-old female patient with a body mass index of 30.5 kg/m(2) was diagnosed with a 3-cm unresectable centrally located intrahepatic cholangiocarcinoma with infiltration of the retrohepatic vena cava, segment VII portal branch, and adjacent to the middle hepatic vein and portal bifurcation. After four cycles of GEMOX, partial response was observed, disappearing vascular infiltration. PVE was required to perform an extended LRH. Consequently, during pedicle dissection, significant inflammation was found in the vicinity of the right portal vein. Thus, the section of the portal and biliary elements was delayed until the transection of the parenchyma reached the hilum. The opening of the parenchyma improved exposure, allowing the safe management of these structures individually.
  
  
  RESULTS
  The total operative time was 438 min. Three periods of 15-min pedicle occlusion resulted in <100 ml bleeding. Hospital stay was 4 days. Pathological examination revealed residual cholangiocarcinoma with intense posttreatment changes (pT1) and tumor-free margins. After an 18-month follow-up, the patient was alive and free of disease.
  
  
  CONCLUSIONS
  LRH is feasible and safe, even after PVE. Nevertheless, periportal inflammation can hinder hilar dissection. In this setting, delaying section of portal and biliary elements until parenchymal transection reaches the hilar region may result in a useful and safe strategy.
authors.affiliation: HPB and Liver Transplant Unit, Department of General and Abdominal Surgery, University Clinic of Navarre, University of Navarre, Pamplona, Spain, frotellar@unav.es.
authors.forename: Fernando
authors.initials: F
authors.lastname: Rotellar
authors.forename: Fernando
authors.initials: F
authors.lastname: Pardo
authors.forename: Alberto
authors.initials: A
authors.lastname: Benito
authors.forename: Pablo
authors.initials: P
authors.lastname: Martí-Cruchaga
authors.forename: Gabriel
authors.initials: G
authors.lastname: Zozaya
authors.forename: Manuel
authors.initials: M
authors.lastname: Bellver
mesh_terms: D001650:Bile Duct Neoplasms; D001653:Bile Ducts, Intrahepatic; D018281:Cholangiocarcinoma / Q000473:pathology / Q000628:therapy*; D003131:Combined Modality Therapy; D004621:Embolization, Therapeutic; D005260:Female; D006498:Hepatectomy; D006503:Hepatic Veins / Q000473:pathology / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D008113:Liver Neoplasms / Q000473:pathology / Q000628:therapy*; D008875:Middle Aged; D011169:Portal Vein / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome